Guillain-Barré Syndrome Physiotherapy Assessment and Management

Guillain-Barré Syndrome Physiotherapy Assessment and Management

1. Definition :
Guillain- Barre Syndrome (GBS) is an acute autoimmune demyelinating poly-neuropathic condition
that results in rapid loss of myelin in peripheral nerves which affects nerve roots and peripheral
nerves leading to motor neuropathy and flaccid paralysis with sensory and autoimmune nervous
system (ANS) effects.
Causes :
GI disturbance (Infection with the bacteria Campylobacter jejuni, which causes gastroenteritis)
Upper respiratory tract infection
Epstein-Barr virus infection
Sign and Symptoms :
Key Features:
History of flu-like symptoms preceding the GBS symptoms
Its Lower Motor Neuron (LMN) Disease which affects peripheral and cranial nerves specially
CN VII, IX, X, XI, XII.
Flaccidity
Sensory loss and paraesthesia (tingling and burning sensation)
Motor loss > Sensory loss
Pain and paraesthesia in calf first
Gloves and stocking like symptoms
Dysphagia
Dysarthria
Diplopia
Fascial weakness in severe cases
10 - 20 % has severe disability, 5% mortality.
Pathophysiology
An autoimmune response that attack host nerve tissue instead of invading pathogen.
When myelin is destroyed, destruction is accompanied by inflammation.
The Schwann cells, which produce myelin in the peripheral nervous system, are destroyed, the
axons are left intact in all but the most severe cases.
Axonal degeneration also seen.
Two to three weeks after the original demyelination, the Schwann cells begin to proliferate,
inflammation subsides, and remyelination begins although myelin sheath is thinner with
disruption of nodes of ranvier which slow down the speed of conduction.
Physiotherapy Notes
Guillain-Barré Syndrome
“GBS has very good
prognosis if treated
on-time.”

2. Common Diagnostic features of GBS
Motor weakness
Progressive symptoms and signs of motor weakness
Rapid Progressive (within 2 weeks)
Relative symmetrical motor involvement
Ascending progression of weakness (distal to proximal), self-limiting to distal limbs of upper
and/or lower extremities.
May extend to full quadriplegia with respiratory and cranial nerve involvement
Areflexia - loss of deep tendon responses(DTR)
Mild sensory signs and symptoms (paresthesias and hypesthesias)
Autonomic dysfunction such as,
Tachycardia
Arrhythmias
Vasomotor symptoms
Absence of fever at onset of symptoms; history of flulike illness common
Laboratory:
May show elevation of cerebrospinal fluid protein
Cerebrospinal fluid cells at 10 or fewer mononuclear leukocytes/cubic mm of cerebrospinal
fluid
Electrodiagnostic testing: Nerve conduction velocities usually abnormal
Recovery usually begins 2 to 4 weeks after plateau of disease process.
Complications of GBS :
Respiratory impairment and failure
Pneumonia (aspiration)
Deep vein thrombosis
Cardiac arrhythmia
Autonomic disability : Tachycardia, Arrhythmia, BP fluctuations
Examination of GBS (Key Features):
HISTORY
Patterns and sequence of symptom onset
Recent illness or injury, prior episodes of sensorimotor problems
H/0 of any infection i.e. respiratory / GI infection
MOTOR FUNCTION
Manual muscle testing, carefully identifying pattern of weakness (testing should be as
muscle specific as possible rather than assessing muscle groups only; use form for serial
recording)
Myotatic reflexes, rule out tonic reflexes (DTR - usually absent / diminished)
Range of motion
Presence of muscle fasciculations

3. Equilibrium reactions sitting and standing (if testable)
Current functional status (activities of daily living, including bowel and bladder function,
ambulation)
Endurance and experienced fatigue
SENSORY FUNCTION:
Pain : Muscle aching / burning / gloves and stocking like sensation
Sensation : Hyperesthesias / Anaesthesia
Pattern of sensory loss
Cranial nerve examination : Specially VII, IX, X, XI, XII
Assess peripheral nerves for sharp/dull discrimination and light touch
AUTONOMIC SYSTEM
Blood pressure resting and immediately after activity (prone, sitting, standing, if possible)
Heart rate resting and immediately after activity, dysrhythmias
Body temperature stability
Bowel and bladder control
ELECTRODIAGNOSTIC TESTING
Nerve conduction velocity - Diminished / Abnormal
EMG - Fibrillation
CARDIAC AND RESPIRATORY EXAMINATION
Check for respiratory complications
O2 saturation level
Forced Vital Capacity (FVC)
Dysphagia / Swallowing
FATIGUE EXAMINATION - Fatigue Severity Scale (FSS) or Fatigue Impact Scale (FIS) can be used.
BALANCE ASSESSMENT
Romberg and Timed Up and Go
Berg Balance Scale
Performance-Oriented Mobility Assessment
FUNCTIONAL ASSESSMENT
Functional Independence Measure (FIM)
Katz Index of Activities of Daily Living
Physiotherapy Management of GBS:
Respiratory and Cranial Nerve Dysfunction
Breathing exercise
Resisted inspiratory muscle training (Prevent Over fatigue of respiratory muscles)
Chest Percussion and postural drainage every 3 hours during acute care.
Mechanical ventilation in early stage
Dysphagia - Prevention of choking and aspiration and the stimulation of effective swallowing
and eating in collaboration with speech consultant

4. Prevention of aspiration
Positioning - upright with head tilted slightly forward
Oral-motor coordination - sucking an ice cube, stimulating the gag response, facilitating
swallowing with quick pressure on the neck and thyroid notch timed with intent to swallow
A conscious swallowing technique is introduced with thick liquids and progressed to thinner
liquids after the patient’s oral-motor coordination response is enough to control movement
of fluids.
Therapists should be prepared to use the Heimlich maneuver if choking occurs.
Positioning
In acute case of rehabilitation, turning at least every 2 hours for both pressure relief and lung
drainage
Use fashion foam“doughnuts” or pads or use sheepskin-type protection for pressure relief.
Use hand and foot splints to decrease potential contractures.
Tilt-table standing program to increase tolerance to upright and to avoid orthostatic
hypotension (wearing positioning splints if necessary)
Positioning splints may be needed for the lower extremities as well as TED stockings to
decrease venous pooling.
Family Education - Family members taught gentle physiological ROM techniques, with attention to
correct shoulder patterns and simple massage techniques.
In the acute GBS, active exercise is limited to whatever the patient can move without pain or
excessive fatigue.
Use the Borg Rating of Perceived Exertion (RPE) for exercise prescription.
Once weakness stops progressing, passive maintenance of ROM may be the only activity possible
for immobile patients.
Range of motion exercises to increase circulation; provide lubrication of the joints; and maintain
extensibility of capsular, muscle, and tendon tissue.
If the ends of ranges start to become stiff, stretch should be slow and sustained at the end point
for 10 to 30 seconds during passive ROM.
As strength begins to return after the plateau, therapists must prescribe limited amounts of low-
resistance activities.
Strictly avoid of antigravity strain on the muscles until strength reaches the 3/5 (Fair) range of
MMT
A Wheel Chair is usually required during the initial few months; selection should consider
avoidance of muscle fatigue, existing strength, need for positioning, and ease of maneuvering in
patient’s home/work environment.
Teach energy conservation technique, activity pacing, avoid overuse and fatigue.
Provide emotional support and reassurance to the patient and family.
Bensman’s recommendations in are still useful guidelines for exercise in GBS:
Use short periods of non-fatiguing exercise matched to the patient’s strength.i.
Increase the difficulty of an activity or level of exercise only if the patient improves or if there
is no deterioration in status after a week.
ii.
Return the patient to bed rest if a decrease in strength or function occurs.iii.
Direct the strengthening exercises at improving function not merely at improving strength.iv.

5. Precautions:
Overuse of painful muscles may result in prolonged recovery period or lack of recovery; frequent
rest periods are recommended.
Signs of overuse weakness are delayed onset of muscle soreness, which gets worse 1 to 5 days
after exercising.
Exercise progression must be taken slowly. Care must be taken to avoid straining weaker muscles
while increasing resistance to those showing good recovery.
Overstretching can occur due to the denervation and weakened muscle.
References:
1.Lazaro RT, Reina-Guerra SG, Quiben M, editors. Umphred's Neurological Rehabilitation-E-
Book: 6th ed. Elsevier Health Sciences; 2013.
i.
1.Martin ST, Kessler M. Neurologic interventions for physical therapy-e-book. Elsevier Health
Sciences; 3rd ed. 2016.
ii.
O'Sullivan SB. National Physical Therapy Examination: Review & Study Guide.22nd ed. 2022iii.
Bensman A. Strenuous exercise may impair muscle function in Guillain-Barré patients. JAMA. 1970; 214: 468–469.iv.
Disclaimer
These physiotherapy study notes are
intended for personal use and reference.
They are not a substitute for any official
course materials, textbooks, or professional
or medical advice. While I’ve made every
effort to ensure accuracy, errors may occur.
Use these notes at your own discretion.
I have made these notes while I was
preparing for my physiotherapy competency
exam (PCE). I have highlighted all important
point for quick review. I have also listed all
references which I have used to prepare
these notes. Please refer them for further
guidance. Avoid overuse of muscles and overstretching